Transurethral Procedures for Lower Urinary Tract Symptoms Resulting From Benign Prostatic Enlargement: A Quality and Meta-Analysis INJ

(1)

INJ

This is an Open Access article distributed under the terms of the Creative Commons Attri- bution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Int Neurourol J 2013;17:59-66 International Neurourology Journal

Transurethral Procedures for Lower Urinary Tract Symptoms Resulting From Benign Prostatic Enlargement: A Quality and Meta-Analysis

Seung Wook Lee, Jong Bo Choi¹, Kyu-Sung Lee², Tae-Hyoung Kim³, Hwancheol Son⁴, Tae Young Jung⁵, Seung-June Oh⁶, Hee Jong Jeong⁷, Jae Hyun Bae⁸, Young-Suk Lee⁹, Joon Chul Kim¹⁰

Department of Urology, Hanyang University College of Medicine, Seoul;

1Department of Urology, Ajou University School of Medicine, Suwon;

2Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicne, Seoul;

3Department of Urology, Chung-Ang University College of Medicine, Seoul;

4Department of Urology, SMG-SNU Boramae Medical Center, Seoul;

5Department of Urology, Veterans Health Service Medical Center, Seoul;

6Department of Urology, Seoul National University Hospital, Seoul;

7Department of Urology, Wonkwang University School of Medicine & Hospital, Iksan;

8Department of Urology, Korea University College of Medicine, Seoul;

9Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon;

10Department of Urology, The Catholic University College of Medicine, Seoul, Korea

Purpose: Thanks to advancements in surgical techniques and instruments, many surgical modalities have been developed to re- place transurethral resection of the prostate (TURP). However, TURP remains the gold standard for the surgical treatment of benign prostatic hyperplasia (BPH). We conducted a meta-analysis on the efficacy and safety of minimally invasive surgical therapies for BPH compared with TURP.

Methods: This meta-analysis used a Medline search assessing the period from 1997 to 2011. A total of 784 randomized controlled trials were identified in an electronic search. Among the 784 articles, 36 randomized controlled trials that provided the highest level of evidence (level 1b) were included in the meta-analysis. We also conducted a quality analysis of selected articles.

Results: Only 2 articles (5.56%) were assessed as having a low risk of bias by use of the Cochrane collaboration risk of bias tool.

On the other hand, by use of the Jadad scale, there were 26 high-quality articles (72.22%). Furthermore, 28 articles (77.78%) were assessed as high-quality articles by use of the van Tulder scale. Holmium laser enucleation of the prostate (HoLEP) showed the highest reduction of the International Prostate Symptom Score compared with TURP (P<0.0001). Bipolar TURP, bipolar transurethral vaporization of the prostate, HoLEP, and open prostatectomy showed superior outcome in postvoid residual urine volume and maximum ﬂow rate. The intraoperative complications of the minimally invasive surgeries had no statistically significant inferior outcomes compared with TURP. Also, there were no statistically significant differences in any of the modalities compared with TURP.

Conclusions: The selection of an appropriate surgical modality for BPH should be assessed by fully understanding each patient’s clinical conditions.

Keywords: Prostatic hyperplasia; Holmium; Lasers; Potassium titanylphosphate; Transurethral resection of prostate; Meta-analysis

Corresponding author: Joon Chul Kim

Department of Urology, Bucheon St. Mary’s Hospital,

The Catholic University of Korea College of Medicine, 327 Sosa-ro 327beon-gil, Wonmi-gu, Bucheon 420-717, Korea

Tel: +82-32-340-7071 / Fax: +82-32-340-2124 / E-mail: kjc@catholic.ac.kr

INTRODUCTION

Benign prostatic hyperplasia (BPH), which causes lower uri-

nary tract symptoms (LUTS), is one of the most common dis- eases of aging men [1]. LUTS can reduce quality of life by imped- ing normal activities and causing complications such as acute

Original Article

http://dx.doi.org/10.5213/inj.2013.17.2.59 pISSN 2093-4777 · eISSN 2093-6931

(2)

Lee, et al. • Transurethral Procedures for Benign Prostatic Enlargement

INJ

urinary retention or urinary tract infection. BPH is histologi- cally observed in about half of men in their 60s and in most men aged 80 and older [2]. Nowadays, various medications are used to treat LUTS resulting from BPH (LUTS/BPH); these include 5-alpha-reductase inhibitors (5-ARIs), alpha-adrenergic blockers, and others. Moreover, many surgical treatment methods have been introduced, such as resection or enucleation.

Currently, the gold standard surgical treatment for LUTS/BPH is transurethral resection of the prostate (TURP) [3,4]. However, TURP is associated with complications including bleeding, pain, infection, urethral stricture, bladder neck contraction, erectile dysfunction, incontinence, and retrograde ejaculation [5]. There- fore, many endoscopic surgical methods have been suggested to replace TURP as the new standard [6]. There has been a continuous rise in the use of minimally invasive surgical therapies for LUTS/BPH, including bipolar TURP, bipolar transurethral vaporization of the prostate (TUVP), holmium laser enucleation of the prostate (HoLEP), and potassium-titanyl-phosphate (KTP) laser vaporization of the prostate. So far, numerous articles have reported on comparisons of these new techniques with TURP.

Ahyai et al. [6] reported a meta-analysis on functional outcomes and complications of transurethral prostatectomy for LUTS/BPH.

According to those authors, many minimally invasive surgical therapies for LUTS/BPH showed statistically comparable efficacy and overall morbidity to TURP. However, that report included randomized controlled trials published from 1997 to 2009.

Therefore, we conducted a meta-analysis on the efficacy and safety of minimally invasive surgical therapies for LUTS/BPH compared with TURP by analyzing more recent articles that were published from 2010 to 2011. In addition, we assessed the quality of these articles by using the Jadad scale, the van Tulder scale (VTS), and Cochrane collaboration risk of bias tool (CCRBT).

MATERIALS AND METHODS

Searching Strategy

This meta-analysis used a Medline search assessing the period from 1997 to 2011. We searched published articles by using MeSH phrases such as “benign prostatic hyperplasia,” “enlargement,” and “obstruction”; “minimally invasive surgical therapy”;

“randomized controlled trial [Publication Type]”; and the spe- cific TURP name. There were no limitations on languages.

Study Selection

A total of 784 randomized controlled trials were identified in

an electronic search. Among the 784 articles, 36 randomized controlled trials that provided the highest level of evidence (level 1b) were included in the meta-analysis. Studies that were not randomized or that had no comparator were excluded.

Data Extraction

We collected the following data: comparator; name of first author; year of publication; number of patients in each group; follow-up period; baseline data, including age, prostate volume (cm³), International Prostate Symptom Score (IPSS), quality of life (QoL) score, postvoiding residual urine volume (PVR; mL), and maximum ﬂow rate (Qmax; mL/sec) before the procedure (Table 1); perioperative outcomes, including operative time (min), weight of resected tissue (g), and length of catheter use (day);

functional outcomes, including IPSS and Qmax after the surgery; and complications (Table 2).

Quality Analysis

We assessed the quality of the selected articles by using the Jadad scale, VTS, and CCRBT [7]. All quality assessments of articles were performed by two reviewers. If there were different outcomes, the two reviewers and a third reviewer resolved the dis- crepancy in the results through discussion.

Statistical Analysis

The primary endpoint of the present analysis was functional outcomes, including IPSS/QoL and Qmax/PVR; perioperative results, including operative time (min) and length of catheter use (day); and incidence rate of complications, including bleeding, blood transfusion, conversion to TURP, capsule perforation, transurethral resection syndrome, acute urinary retention, clot retention, secondary apical resection, secondary coagulation revision, secondary bleeding, infection, urethral stricture, bladder neck stenosis, urgency, stress urinary incontinence, and re- operation/intervention requirement. Pooled odds ratios and 95% confidence intervals were calculated for the dichotomous and continuous outcome data between the various operative methods and TURP, respectively. The Q-statistic was used to analyze heterogeneity [8]. If I2 >50%, we considered it as het- erogeneous and a random effect model was performed. IBM SPSS ver. 18.0 (IBM Co., Armonk, NY, USA) and SAS ver. 9.1.3 (SAS Institute, Cary, NC, USA) were used for the statistical analysis. All tests were two-sided, with a significance level of 0.05.

(3)

INJ

Table 1. Summary of (mean) baseline characteristics from included randomised trials comparing minimally invasive therapies with transurethral resection of the prostate

Publication

year Author^a) Comparator No. of

patients Follow-up

(yr) Age

(yr) Prostate

volume (cm³) IPSS QoL Qmax

(mL/sec) PVR (mL) 2011 Geavlete et al. [S-1] BPVP vs. TURis 170; 170; 170 1.5 N/A 54.1; 53.7; 54.8 24.3; 24.0; 24.2 4.3; 4.5; 4.3 6.6; 6.1; 6.4 91; 96; 88

2011 Fagerstroml et al. [S-2] Bipolar TURP 90; 95; 185 1.5 69.5; 72.7 55.6; 58.2 21.7; 20.4 3.9; 3.7 N/A N/A

2011 Fayad et al. [S-3] HoLEP vs. Bipolar TURP 30; 30 0.5 60.0; 61.2 76.5; 80.6 22.6; 22.2 N/A 7.4; 6.9 N/A

2010 Chen et al. [S-4] Bipolar TURP (TURis) 50; 50 2.0 69.7; 71.2 60.2; 59.1 22.8; 21.8 N/A 7.1; 7.9 73.1; 80

2010 Zhao et al. [S-5] Plasmakinetic enucleation 102; 102 3.0 67.3; 67.8 69.2; 67.5 23.2; 22.4 4.5; 4.8 8.3; 8.0 92; 97

2010 Al-Ansari et al. [S-6] KTP 60; 60 3.0 66.3; 67.1 61.8; 60.3 27.2; 27.9 N/A 6.9; 6.4 53.2; 57

2010 Simforoosh et al. [S-7] Open 51; 49 1.0 71.7; 61.0 47.9; 44.4 27.1; 27.1 N/A 7.0; 8.1 62; 47

2010 Ou et al. [S-8] Open 34; 35 1.0 71.3; 70.9 138.4; 131.0 23.1; 21.7 4.4; 4.3 5.0; 6.2 80.3; 92.7

2010 Elmansy et al. [S-9] HoLEP vs. PVP 57; 52 4.0 72.7; 71.6 33.1; 37.3 20; 18.4 3.8; 3.6 6.7; 6.4 205; 215

2008 Horasanli et al. [S-10] KTP 39; 37 0.5 69.2; 68.3 86; 88 18.9; 20.2 N/A 8.6; 9.2 183.0; 176.9

2008 Alivizatos et al. [S-11] KTP vs. open 65; 60 1.0 74.0; 67.5 93.0; 96.0 20.0; 21.0 3.0; 3.0 8.6; 8.0 97.0; 89.0

2008 Iori et al. [S-12] Bipolar TURP 26; 25 1.0 65.0; 63.0 49.0; 48.0 21.0; 20.0 3.0; 3.6 7.0; 8.7 99.0; 96.0

2008; 2002 Kuntz and Lehrich [S-13,14] HoLEP vs. open 60; 60 5.0 69.2; 71.2 114.6; 113.0 22.1; 21.0 N/A 3.8; 3.6 280

2007 Michielsen et al. [S-15] Bipolar TURP 118; 120 1.5 73.8; 73.1 N/A N/A N/A N/A N/A

2007; 2006 de Sio et al. [S-16] Bipolar TURP 35; 35 3.0 59.0; 61.0 51.6; 47.5 24.2; 24.3 4.2; 3.9 7.1; 6.9 80.0; 75.0

2007 Ho et al. [S-17] Bipolar TURP 48; 52 1.0 66.6; 66.5 56.5; 54.8 22.6; 24.6 N/A 6.8; 6.5 N/A

2007 Kaya et al. [S-18] Bipolar TUVP 25; 15 3.0 67.2; 66.0 50.0; 51.0 21.0; 22.0 N/A 6.0; 6.0 N/A

2007; 2004 Kuntz and Lehrich [S-19]/ HoLEP 100; 100 3.0 68.0; 68.7 53.5; 49.9 22.1; 21.4 N/A 45.9; 5.9 238.0; 216.0

Ahyai and Leihrich [S-20]

2006 Patankar et al. [S-21] Bipolar TURP 53; 51 0.1 64.0; 62.0 51.3; 52.3 23.3; 23.7 N/A 5.9; 6.4 N/A

2006 Nuhoglu et al. [S-22] Bipolar TURP 27; 30 1.0 64.6; 65.2 47.0; 49.0 17.6; 17.3 N/A 6.9; 7.3 96.0; 88.0

2006 Gupta et al. [S-23] HoLEP 50; 50 1.0 65.8; 65.7 57.9; 59.8 23.4; 23.3 N/A 5.2; 4.5 112.0; 84.0

2006 Neill et al. [S-24] HoLEP 30; 30 2.0 71.7; 70.3 77.8; 70.0 26.0; 23.7 4.8; 4.7 8.4; 8.3 N/A

2006 Naspro et al. [S-25] HoLEP vs. open 41; 39 2.0 66.3; 67.3 113.3; 124.2 20.1; 21.6 4.1; 4.4 7.8; 8.3 N/A

2006 Bouchiers-Hayes et al. [S-26] KTP 38; 38 1.0 65.2; 66.2 42.4; 33.2 N/A N/A N/A 147.0; 119.0

2006 Hon et al. [S-27] Bipolar TUVP 81; 79 0.7 66.1; 68.1 38.0; 40.0 21.3; 20.6 4.2; 4.3 12.0; 11.9 147.0; 182.0

2005 Singh et al. [S-28] Bipolar TURP 30; 30 0.3 68.9; 67.9 24.1; 27.9 20.5; 21.6 4.6; 4.4 5.8; 5.1 124.0; 136.0

2005 Seckiner et al. [S-29] Bipolar TURP 24; 24 1.0 61.2; 63.9 49.4; 41.4 24.1; 23.2 4.4; 4.7 8.5; 8.3 88.0; 138.0

2005 Fung et al. [S-30] Bipolar TURP 21; 30 0.3 72.5; 73.0 N/A 15.8; 19.4 3.6; 3.6 N/A N/A

2005 Tefekli et al. [S-31] Bipolar TUVP 51; 50 1.0 68.7; 69.4 50.1; 50.4 21.3; 20.4 N/A 7.8; 8.3 N/A

2004 Yang et al. [S-32] Bipolar TURP 58; 59 0.3 N/A 46; 49 20.9; 21.6 3.7; 4.0 10.4; 10.9 99.0; 150

2004 Montorsi et al. [S-33] HoLEP 52; 48 1.0 65.1; 64.5 70.3; 56.2 21.6; 21.9 4.6; 4.7 8.2; 7.8 N/A

2003 Dumsumir et al. [S-34] Bipolar TUVP 30; 21 1.0 63.0; 60.0 36.0; 42.0 24.0; 17.0 N/A 9.6; 10.4 112.0; 96.0

IPSS, International Prostate Symptom Score; QoL, quality of life; Qmax, maximum flow rate; PVR, postvoid residual urine volume; BPVP, bipolar plasma vaporization of the prostate; TURis, transurethral resection of prostate in saline; N/A, not available; TURP, transurethral resection of prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate; PVP, plasma vaporization of the prostate; TUVP, transurethral vaporisation of the prostate.

a)Supplementary material for authors can be found via http://www.einj.org/src/sm/inj-17-59-s001.pdf.

RESULTS

Quality Analysis of Selected Articles

Among the 36 articles, only 2 articles (5.56%) were assessed as having a low risk of bias, 7 articles (19.44%) were assessed as having a moderate risk of bias, and 27 articles (0.75%) were evaluated as having a high risk of bias by use of the CCRBT. On the other hand, by use of the Jadad scale, there were 26 high-quality arti-

cles (72.22%). Furthermore, 28 articles (77.78%) were assessed as high-quality articles by use of the VTS.

Meta-Analysis of Functional Outcomes IPSS (Fig. 1) and QoL (Fig. 2)

Only KTP laser vaporization of the prostate showed an inferior outcome compared with TURP (P=0.0272). Otherwise, HoLEP showed the highest reduction of the IPSS compared with TURP

(4)

INJ

Table 2. Summary of (mean) outcome data from included randomised studies comparing minimally invasive surgical therapies with transurethral resection of the prostate

Author^a) Comparator Operating time

(min) Resected

tissue (gm) Catheterization

time (day) IPSS QoL Qmax

(mL/sec) PVR

(mL) Geavlete et al. [S-1] BPVP vs. TURis vs. TURP 39.7; 52.1; 55.6 N/A 0.9; 1.9; 3.0 5.0; 7.9; 8.3 1.0; 1.3; 1.5 23.7; 20.6; 20.2 29; 31; 33

Fagerstroml et al. [S-2] Bipolar TURP 62; 66 27.3; 26.3 0.8; 0.8 7.1; 7.6 0.9; 1.1 N/A N/A

Fayad et al. [S-3] HoLEP vs. Bipolar TURP 110.5; 76.5 55.9; 65.6 N/A 5.5; 5.3 N/A 20.8; 20.5 20.3; 25.6

Chen et al. [S-4] Bipolar TURP (TURis) 59; 60 40; 38.9 N/A 3.7; 3.8 N/A 25.5; 24.8 N/A

Zhao et al. [S-5] Plasmakinetic enucleation 62.8; 55.3 56.4; 43.8 2.2; 3.4 2.4; 4.3 0.6; 1.6 28.8; 25.1 5.0; 5.4

Al-Ansari et al. [S-6] KTP 89; 80 N/A 1.4; 2.7 10.9; 9.2 N/A 17.2; 20 12.5; 10.5

Simforoosh et al. [S-7] Open N/A 34.5; 31.0 7; 5 4.8; 6.7 2.3; 2.8 18.1; 16.1 2.0; 2.5

Ou et al. [S-8] Open 109.5; 103.7 116.8; 69.7 7.5; 4.1 2.8; 8.1 1.26; 2.5 16.4; 12.5 9.12; 27.3

Elmansy et al. [S-9] HoLEP vs. PVP 69.8; 55.5 N/A 2.1; 1.6 5.9; 6.6 1.1; 1.2 17.7; 18.5 38.8; 43.9

Horasanli et al. [S-10] KTP 87; 51 N/A 1.7; 3.9 13.1; 6.4 N/A 13.3; 20.7 79; 23

Alivizatos et al. [S-11] KTP vs. Open 80.0; 50.0 0.0; 73.5 1.0; 5.0 9.0; 8.0 1.0; 1.0 16.0; 15.1 17; 12

Iori et al. [S-12] Bipolar TURP 39.1; 31.7 N/A 1.0; 1.3 7.0; 6.7 1.0; 1.0 24.2; 23.2 20.0; 27.0

Kuntz and Lehrich [S-13,14] HoLEP vs. Open 135.9; 90.6 93.7; 96.4 1.8; 8.1 3.0; 3.2 N/A 24.3; 24.4 10.6; 5.3

Michielsen et al. [S-15] Bipolar TURP 56.0; 44.0 21.0; 21.3 4.0; 4.5 N/A N/A N/A N/A

de Sio et al. [S-16] Bipolar TURP 49.0; 53.0 20.0; 24.0 3.0; 4.2 6.8; 6.2 1.0; 0.8 20.5; 21.5 25.0; 20.0

Ho et al. [S-17] Bipolar TUVP N/A N/A N/A 7.6; 14.4 N/A 5.7; 21.8 N/A

Kaya et al. [S-18] HoLEP 94.6; 73.8 35.9; 37.2 1.0; 2.0 3.0; 10.0 N/A 29.0; 27.5 8; 20

Kuntz and Lehrich [S-19]/ Bipolar TURP 50.0; 57.9 N/A 0.8; 1.8 6.1; 7.7 N/A 19.2; 20.7 N/A

Ahyai and Leihrich [S-20]

Patankar et al. [S-21] Bipolar TURP 55.0; 52.0 N/A 1.8; 3.2 5.4; 4.7 N/A 17.1; 17.9 N/A

Nuhoglu et al. [S-22] HoLEP 75.4; 62.6 17.2; 24.2 1.2; 2.0 5.2; 5.6 N/A 25.1; 23.7 20.0; 20.0

Gupta et al. [S-23] HoLEP 62.1; 33.1 40.4; 24.7 0.7; 1.9 6.1; 5.2 1.25; 1.3 21.0; 19.0 33.7; 51.8

Neill et al. [S-24] HoLEP vs. Open 72.1; 58.3 59.3; 87.9 1.5; 4.1 7.9; 8.1 1.5; 1.66 19.2; 20.1 N/A

Naspro et al. [S-25] KTP 31.3; 30.2 N/A 0.51; 1.9 12.0; 12.4 N/A 19.9; 20.6 37; 27

Bouchiers-Hayes et al. [S-26] Bipolar TUVP 32.6; 28.5 0.0;21.5 N/A 7.7; 6.9 1.7; 1.5 25.6; 23.5 64.0; 69.0

Hon et al. [S-27] Bipolar TURP 39.3; 36.9 24.0; 27.6 2.5; 3.4 5.3; 6.2 1.1; 1.0 19.0; 17.8 N/A

Singh et al. [S-28] Bipolar TURP 52.9; 52.9 36.6; 31.9 3.1; 3.1 8.7; 8.3 1.8; 2.0 18.8; 15.7 N/A

Seckiner et al. [S-29] Bipolar TURP 36.6; 32.9 18.6; 25.1 1.1; 1.2 7.0; 9.7 N/A 16.6; 14.7 N/A

Fung et al. [S-30] Bipolar TUVP 40.3; 57.8 N/A 2.3; 3.8 7.9; 7.3 N/A 17.2; 16.9 N/A

Tefekli et al. [S-31] Bipolar TURP 46.0; 55.0 N/A 2.7; 3.2 10.8; 11.1 2.1; 2.2 17.1; 14.8 13.9; 34.5

Yang et al. [S-32] HoLEP 74.0; 57.0 36.1; 25.4 1.3; 2.4 4.1; 3.9 1.4; 0.8 25.1; 24.7 N/A

Montorsi et al. [S-33] Bipolar TUVP 33.0; 26.0 0.0; 8.0 0.8; 0.7 6.0; 5.0 N/A 18.0; 16.0 90.0; 80.0

IPSS, International Prostate Symptom Score; QoL, quality of life; Qmax, maximum flow rate; PVR, postvoid residual urine volume; BPVP, bipolar plasma vaporization of the prostate; TURis, transurethral resection of prostate in saline; TURP, transurethral resection of prostate; N/A, not available; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate; PVP, plasma vaporization of the prostate; TUVP, transurethral vaporisation of the prostate.

a)Supplementary material for authors can be found via http://www.einj.org/src/sm/inj-17-59-s001.pdf.

(P<0.0001). Moreover, only HoLEP showed a higher QoL, al- though it was not statistically significant (P=0.1252).

Maximum flow rate (Fig. 3) and postvoid residual urine volume (Fig. 4)

Only KTP showed an inferior outcome in Qmax and PVR (P=

0.1407, P=0.0058). However, bipolar TURP, bipolar TUVP, HoLEP, and open prostatectomy showed a superior outcome in

Qmax and PVR. Open prostatectomy and HoLEP could not be statistically analyzed for PVR owing to insufficient data.

Meta-Analysis of Complications Of Surgery Intraoperative complications (Fig. 5)

No surgical methods showed statistically significant inferior outcomes compared with TURP. However, HoLEP showed the highest complication rate (P=0.0710) and KTP showed a sta-

(5)

INJ

tistically significantly lower complication rate than TURP (P<

0.0001). HoLEP showed the highest incidence of bladder mucosal injury, and TURP showed the highest incidence of intraoperative transfusion (Table 3).

Perioperative complications (Fig. 6)

KTP and HoLEP showed statistically significantly inferior outcomes compared with TURP (P<0.0001, P=0.0342, respectively). Acute urinary retention, secondary apical resection, and fe- brile urinary tract infection occurred most commonly with KTP.

TURP showed the highest occurrence rate of clot retention and hematuria episodes (Table 4).

Late complications (Fig. 7)

There were no statistically significant differences in any of the modalities compared with TURP. However, bladder neck contracture, urethral stricture, dysuria, and reintervention episode occurred more commonly in the KTP group than in the others (Table 5).

DISCUSSION

BPH results from the proliferation of smooth muscle cells and epithelial cells in the prostatic transitional zone [9]. The treatment of LUTS/BPH is aimed at improving QoL and preventing complications such as urinary tract infection and urinary retention. Treatment methods are largely divided into surgery, medi-

Fig. 1. Forest plot of International Prostate Symptom Score (IPSS).

CI, confidence interval; TURP, transurethral resection of the prostate; IPSS, International Prostate Symptom Score; TUVP, transurethral vaporization of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

Study Mean differnce 95% CI IPSS

P=0.0003 Bipolar TURP vs TURP -0.13 -0.231 to -0.0289 P<0.0001 Bipolar TUVP vs TURP -0.3 -0.432 to -0.168 P<0.0001 HoLEP vs TURP -1.46 -1.676 to -1.245 P=0.0272 KTP vs TURP 0.36 0.119 to 0.601 P<0.0001 Open vs TURP -0.538 -0.848 to -0.228

Total (fixed effects) -0.297 -0.367 to -0.228 Total (random effects) -0.412 -0.889 to 0.0652

-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0

Fig. 2. Forest plot of quality of life (QoL, question 8 of the IPSS).

CI, confidence interval; TURP, transurethral resection of the prostate; IPSS, International Prostate Symptom Score; TUVP, transurethral vaporization of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

QoL

Study Mean differnce 95% CI P=0.5418 Bipolar TURP vs TURP -0.179 -0.280 to -0.0783 P=0.0044 Bipolar TUVP vs TURP -0.269 -0.401 to -0.137 P=0.1252 HoLEP vs TURP 0.568 0.373 to 0.763 P=0.001 Open vs TURP -0.744 -1.059 to -0.429

Total (fixed effects) -0.133 -0.205 to -0.0611 Total (random effects) -0.144 -0.528 to 0.240

-1.5 -1.0 -0.5 0.0 0.5 1.0

Fig. 3. Forest plot of maximum flow rate (Qmax). CI, confidence interval; TURP, transurethral resection of the prostate; IPSS, In- ternational Prostate Symptom Score; TUVP, transurethral vaporization of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

Study Mean differnce 95% CI Qmax

P=0.0012 Bipolar TURP vs TURP 0.111 0.00988 to 0.212 P<0.0001 Bipolar TUVP vs TURP 0.154 0.0223 to 0.286 P=0.0023 HoLEP vs TURP 0.223 0.0313 to 0.415 P=0.1407 KTP vs TURP -0.361 -0.601 to -0.120 Open vs TURP 0.593 0.282 to 0.905 Total (fixed effects) 0.122 0.0534 to 0.191 Total (random effects) 0.132 -0.0635 to 0.327

-1.0 -0.5 0.0 0.5 1.0

Fig. 4. Forest plot of postvoid residual urine volume (PVR). CI, confidence interval; TURP, transurethral resection of the prostate; IPSS, International Prostate Symptom Score; TUVP, transurethral vaporization of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

Study Mean differnce 95% CI PVR

Bipolar TURP vs TURP -0.1 -0.201 to 0.000569 P=0.0235 Bipolar TUVP vs TURP -0.0438 -0.175 to 0.0878

HoLEP vs TURP -0.852 -1.052 to -0.653 P=0.0058 KTP vs TURP 0.426 0.185 to 0.668 Open vs TURP -0.354 -0.662 to -0.0474 Total (fixed effects) -0.145 -0.214 to -0.0757 Total (random effects) -0.184 -0.513 to 0.145

-1.5 -1.0 -0.5 0.0 0.5 1.0

(6)

INJ

cal treatment, and watchful waiting [10]. Watchful waiting is applicable to patients with mild symptoms or with moderate- to-severe symptoms but no complications. This treatment option requires measurement of prostate volume and Qmax an- nually [11]. For medical management, representative drugs are 5-ARIs and alpha-adrenergic blockers. 5-ARI lowers the serum

dihydrotestosterone level and reduces the volume of the prostate [12]. Alpha-adrenergic blockers improve voiding symptoms by relaxation of smooth muscle in the prostate [13]. However, when patients have concomitant complications such as hematuria, infection, or urinary tract obstruction, surgical management is warranted [14]. Many surgical techniques have been

Fig. 5. Forest plot of intraoperative complications. TURP, trans- urethral resection of the prostate; OR, odds ratio; CI, confidence interval; TUVP, transurethral vaporization of the prostate; Ho- LEP, holmium laser enucleation of the prostate; KTP, potassium- titanyl-phosphate.

Intraoperative complication

Study OR 95% CI

P=0.0150 Bipolar TURP vs TURP 0.525 0.329 to 0.840 P<0.0001 Bipolar TUVP vs TURP 0.131 0.0552 to 0.313 P=0.0710 HoLEP vs TURP 2.787 0.874 to 8.886 P<0.0001 KTP vs TURP 0.0131 0.000793 to 0.217 P=0.4480 Open vs TURP 0.689 0.263 to 1.810

Total (fixed effects) 0.371 0.269 to 0.511 Total (random effects) 0.399 0.131 to 1.213

0.0001 0.01 1

Fig. 6. Forest plot of perioperative complications. OR, odds ratio;

CI, confidence interval; TURP, transurethral resection of the prostate; TUVP, transurethral vaporization of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

Perioperative complication

Study OR 95% CI

P=0.0350 Bipolar TURP vs TURP 0.689 0.486 to 0.976 P=0.0170 Bipolar TUVP vs TURP 0.56 0.345 to 0.907 P=0.0342 HoLEP vs TURP 1.989 1.165 to 3.398 P<0.0001 KTP vs TURP 4.058 2.404 to 6.850 P=0.4260 Open vs TURP 0.469 0.136 to 1.622 Total (fixed effects) 1.09 0.882 to 1.347 Total (random effects) 1.127 0.508 to 2.503

0.1 1 10

Table 3. Intraoperative complications

Procedure Bleeding Capsular

perforation Conversion

to TURP Bladder

mucosal injury Transfusion TUR

syndrome Total

TURP (%) 1.7 1.8 0 0 4.3 0.9 8.7

Bipolar TURP (%) 1.7 1.5 0 0 2 0 5.5

Bipolar TUVP (%) 0.6 0.4 0 0 0.6 0 1.6

HoLEP (%) 0 0.2 0 2.6 0 0 2.8

KTP (%) 0 0 1.9 0 0 0 1.9

TURP, transurethral resection of prostate; TUVP, transurethral vaporisation of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

Table 4. Perioperative complication

Procedure AUR Clot

retention

Secondary apical resection

Secondary

coagulation Delay

bleeding Episodes of

hematuria Urosepsis UTI, fever Total

TURP (%) 3.7 4.5 0.1 0.6 0.9 3.8 0.1 3.8 17.5

Bipolar TURP (%) 3.3 2.6 0 0 0.8 1.5 0 2.2 10.4

Bipolar TUVP (%) 3.9 2.4 0 0 0.9 0 0 1.3 8.5

HoLEP (%) 4.6 0 0.4 1.1 0 0 0 0.6 6.7

KTP (%) 5.5 0 1.2 0 0.4 0 0 6.7 13.8

AUR, acute urinary retention; UTI, urinary tract infection; TURP, transurethral resection of prostate; TUVP, transurethral vaporisation of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

(7)

INJ

developed, such as open prostatectomy, HoLEP, KTP, TURP, bipolar TURP, and bipolar TUVP. Until now, TURP has remained the gold standard treatment option for LUTS/BPH [11]. How- ever, TURP faces many challenges, such as morbidity and functional outcomes [15].

TURP

Accord to our results, TURP was one of the most effective surgical modalities for relieving the obstruction due to BPH. This method needed less reintervention and showed effectiveness for relieving the voiding symptoms, including reduction of IPSS and improvement of Qmax. However, as shown in Tables 3 and 4, TURP has many intraoperative and perioperative complications, such as bleeding, clot retention, and transfusion. None- theless, the late complication rate was not inferior compared with other surgical methods. Considering these results, TURP is a worthy mode of surgical intervention for treating LUTS/BPH.

Bipolar TURP

In our meta-analysis, bipolar TURP showed comparable functional outcomes to TURP. Moreover, bipolar TURP showed a shorter length of Foley catheterization and lower intraoperative and perioperative complications. However, to replace TURP, long- term, large-scale, randomized controlled trials will be needed.

HoLEP

Many articles have shown that for large prostates, HoLEP shows superior functional outcomes to open prostatectomy [16,17].

Some parameters of HoLEP, such as length of hospital stay and duration of Foley catheterization, showed supremacy to TURP.

Moreover, HoLEP seemed to be effective for avoiding intraoperative and perioperative complications, even though it showed bladder mucosal injury during morcellation of resected prostate adenoma. To confirm the effectiveness and safety of HoLEP, many studies should be performed in relatively small prostates, and long-term comparative studies are needed.

KTP Laser Vaporization of the Prostate

For small to moderate prostate volume, KTP showed comparable functional outcomes, such as for Qmax, PVR, IPSS, and QoL, to TURP. Also, KTP had some benefits, such as a lower incidence of intraoperative complications compared with TURP in patients with a small to moderate prostate volume. However, KTP showed a higher incidence of late complications, such as bladder neck contracture and urethral stricture. Thus, long-term, large-scale randomized controlled studies, conducted for large prostates, should be conducted to prove the usefulness and safety of KTP.

We conducted a meta-analysis of transurethral surgeries for LUTS/BPH. It will be helpful to identify the advantages and disadvantages of each surgical modality. However, we conducted the meta-analysis without a quality analysis of the articles.

This is a limitation of the present study even though we per- Fig. 7. Forest plot of late complications. OR, odds ratio; CI, con-

fidence interval; TURP, transurethral resection of the prostate;

TUVP, transurethral vaporization of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanylphosphate.

Late complication

Study OR 95% CI

P=0.0496 Bipolar TURP vs TURP 0.835 0.497 to 1.403 P=0.1790 Bipolar TUVP vs TURP 0.675 0.379 to 1.202 P=0.2500 HoLEP vs TURP 0.653 0.315 to 1.356 P=0.7770 KTP vs TURP 1.191 0.355 to 3.999 P=0.0520 Open vs TURP 0.155 0.0182 to 1.315

Total (fixed effects) 0.720 0.522 to 0.993 Total (random effects) 0.734 0.530 to 1.015

0.01 0.1 1 10

Table 5. Late operative complication

Procedure Bladder neck

contracture Urethral

stricture Reinterven-

tion Secondary

treatment Transient

dysuria Urgency Stress urinary

incontinence Total

TURP (%) 2.0 3.7 1.5 0.6 4.8 2.5 0.9 16.0

Bipolar TURP (%) 1.2 3.0 1.2 1.2 2.3 1.2 0.3 10.4

Bipolar TUVP (%) 0.7 2.6 1.5 0.6 5.2 1.9 0.2 12.7

HoLEP (%) 1.6 4.0 0.9 0 0.9 4.4 0.9 12.7

KTP (%) 5.9 4.7 6.7 0 15.7 0 0.7 33.7

TURP, transurethral resection of prostate; TUVP, transurethral vaporisation of the prostate; HoLEP, holmium laser enucleation of the prostate; KTP, potassium-titanyl-phosphate.

(8)

INJ

formed our analysis of the articles that showed the highest level of evidence.

In conclusion, this study showed statistically comparable efficacy and overall morbidity of transurethral surgeries compared with TURP. Functional outcomes and complications at each step varied for each modality. The selection of an appropriate surgical modality for BPH should be assessed by fully understanding each patient’s clinical conditions.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

SUPPLEMENTARY MATERIALS

Supplementary material can be found via http://www.einj.org/

src/sm/inj-17-59-s001.pdf.

REFERENCES

1. Lepor H. Pathophysiology, epidemiology, and natural history of benign prostatic hyperplasia. Rev Urol 2004;6 Suppl 9:S3-10.

2. Hoke GP, McWilliams GW. Epidemiology of benign prostatic hyperplasia and comorbidities in racial and ethnic minority popula- tions. Am J Med 2008;121(8 Suppl 2):S3-10.

3. Speakman MJ. Who should be treated and how? Evidence-based medicine in symptomatic BPH. Eur Urol 1999;36 Suppl 3:40-51.

4. Souverein PC, Erkens JA, de la Rosette JJ, Leufkens HG, Herings RM. Drug treatment of benign prostatic hyperplasia and hospital admission for BPH-related surgery. Eur Urol 2003;43:528-34.

5. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP): incidence, management, and prevention. Eur Urol 2006;50:969-79.

6. Ahyai SA, Gilling P, Kaplan SA, Kuntz RM, Madersbacher S, Mon- torsi F, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol 2010;58:384-97.

7. Chung JH, Kang DH, Jo JK, Lee SW. Assessing the quality of randomized controlled trials published in the Journal of Korean Medi- cal Science from 1986 to 2011. J Korean Med Sci 2012;27:973-80.

8. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring in- consistency in meta-analyses. BMJ 2003;327:557-60.

9. Auffenberg GB, Helfand BT, McVary KT. Established medical therapy for benign prostatic hyperplasia. Urol Clin North Am 2009;36:

443-59.

10. Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJ. EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines). Eur Urol 2004;46:

547-54.

11. McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol 2011;185:1793-803.

12. Marberger M, Harkaway R, de la Rosette J. Optimising the medical management of benign prostatic hyperplasia. Eur Urol 2004;45:

411-9.

13. Chapple CR. Alpha adrenoceptor antagonists in the year 2000: is there anything new? Curr Opin Urol 2001;11:9-16.

14. Taylor J, Harrison SC, Assassa RP, McGrother CW; Leicestershire MRC Incontinence Study Group. The pattern and progression of lower urinary tract symptoms after transurethral prostatectomy compared with those seen in the general population. Eur Urol 2007;

51:1023-9.

15. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A co- operative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989;141:243-7.

16. Naspro R, Suardi N, Salonia A, Scattoni V, Guazzoni G, Colombo R, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up. Eur Urol 2006;

50:563-8.

17. Kuntz RM, Lehrich K. Transurethral holmium laser enucleation versus transvesical open enucleation for prostate adenoma greater than 100 gm.:: a randomized prospective trial of 120 patients. J Urol 2002;168(4 Pt 1):1465-9.